History

Fact Explanation
Asymptomatic. About 50% are asymptomatic and do not require treatment unless they are pregnant. [1]
Fishy smelling, thin, homogenous, pale vaginal discharge. [2] Noticed mainly after intercourse. Alteration of vaginal flora from normally present Lactobacilli to abnormal Gardnerella vaginalis, anaerobic gram-negative rods of Prevotella, Bacteroides; Peptostreptococcus, Mycoplasma hominis, Ureaplasma urealyticum, and Mobiluncus occurs in bacterial vaginosis.They produce amine which with alkaline medium gives a fishy smell. Semen is alkaline, thus the smell is more prominent after intercourse.
References
  1. AMSEL R, Totten PA, SPEIGEL CA, CHEN KC, ESCHENBACH D, HOLMES KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. The American Journal of Medicine 1983 Jan; Volume 74. Issue 1. Pages 14-22. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pubmed?term=6600371
  2. MONEY Deborah MD FRCSC, The laboratory diagnosis of bacterial vaginosis, Canadian journal of infectious diseases and medical microbiology. 2005 March-April; Volume 16. Issue 2. Pages 77-79 Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095014/

Examination

Fact Explanation
Vaginal examination- reveals thin, white, homogenous discharge This along with pH of the vaginal discharge >4.5, positive “whiff test”, presence of clue cells in microscopy consist of the Amsel's criteria for diagnosis of bacterial vaginosis. [1] But the gram stain method has been proven as a more effective method of diagnosis. [2]
Speculum examination [3] -A smear can be obtained[4] and thin, white, homogenous discharge can be observed Exclude other causes of vaginal discharge such as cervical polyp, cervicitis (Presence of mucopurulent discharge with contact bleeding of cervix [5]).
pH > 4.5 Due to lack of hydrogen peroxide procucing Lactobacillus.
If the women is pregnant, examine the abdomen and follow up. There is increased risk of pre term birth and premature rupture of membrane in cases of bacterial vaginosis in early pregnancy. [6]
References
  1. KEANE F, C A ISON, H NOBLE, C ESTCOURT. Bacterial vaginosis. Sexually Transmitted Infections. Dec 2006. Volume 82. Viewed on: 11/03/2014 Available from: PMC2563898 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563898/
  2. TAM M T, M YUNGBLUTH, and T MYLES. Gram stain method shows better sensitivity than clinical criteria for detection of bacterial vaginosis in surveillance of pregnant, low-income women in a clinical setting. Infectious Disease in Obstetrics and Gynecology.1998. Volume 6. Issue 5. Viewed on: 11/03/2014 Available from: PMC1784815, doi: 10.1002/(SICI)1098-0997(1998)6:5<204::AID-IDOG3>3.0.CO;2-R
  3. SINGH RH, ZENILMAN JM, BROWN KM, MADDEN T, GAYDOS C, GHANEM KG. The role of physical examination in diagnosing common causes of vaginitis: a prospective study. Sexually Transmitted Infections. 2013 May. Volume 89. Issue 3. Pages 185-90.Viewed on: 11/03/2014 Available from: doi: 10.1136/sextrans-2012-050550. Epub 2012 Sep 27. http://www.ncbi.nlm.nih.gov/pubmed/23019659
  4. MONEY Deborah MD FRCSC, The laboratory diagnosis of bacterial vaginosis, Canadian journal of infectious diseases and medical microbiology. 2005 March-April; Volume 16. Issue 2. Pages 77-79 Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095014/
  5. MARRAZZO Jeanne M, Harold C. WIESENFELD, Pamela J. MURRAY, Barbara BUSSE, Leslie MEYN, Marijane KROHN and Sharon L. HILLIER. Risk Factors for Cervicitis among Women with Bacterial Vaginosis. Oxford Journals Medicine, The Journal of Infectious Diseases, Volume 193, Issue 5, Pg. 617-624 Viewed on: 11/03/2014 http://jid.oxfordjournals.org/content/193/5/617.full?sid=118b439b-f497-45f9-94e4-580ff68c9718
  6. PURWAR M, UGHADE S, BHAGAT B, AGARWAL V, KULKARNI H. Bacterial vaginosis in early pregnancy and adverse pregnancy outcome. Journal of Obstetrics and Gynaecology Researches 2001 Aug; Volume 27. Issue 4. Pages 175-81. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/11721727

Differential Diagnoses

Fact Explanation
Physiological vaginal discharge. This is a clear, non-offensive vaginal discharge that changes according to days of menstrual cycle.[1] It is copious just before ovulation due to increased estrogen augmenting growth and secretion of cervical glands.[2]
Trichomoniasis Suspect if itching, soreness, discomfort on urination or dyspareunia is present. The discharge is usually greenish yellow in color.[3][4]
Candidiasis Suspect if vulval itching, soreness, dyspareunia, non malodourous whitish "cottage cheese like"[4] discharge is present. [5]
Cervical carcinoma [6] Suspect if vaginal discharge is foul smelling and in elderly women. Bare in mind other rare conditions such as vaginal carcinoma.
Cervicitis [7] Suspect if discharge is mucopurulent and history of post coital bleeding is present. Speculum examination will aid in examination of the discharge and contact bleeding maybe demonstrated. [8]
Cervical polyp Will be seen in speculum examination.
References
  1. SPENCE D, Catriona MELVILLE. Vaginal discharge. BMJ volume 335(7630); Dec 1, 2007, Viewed on: 11/03/2014 Available from: PMC2099568 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2099568/
  2. WATSON William J, MD, CCFP, Gregory DeMARCHI, MD, CCFP. Vaginal discharge: An approach to diagnosis and management. Canadian family physician. Aug 1987, volume 33; Viewed on: 11/03/2014 Available from: PMC2218224. View on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2218224/?page=1
  3. National Institute for Health and Care Excellence guidelines. Viewed on 11/03/2014 http://cks.nice.org.uk/trichomoniasis#!diagnosissub:4
  4. KELLY Karen G. Chapter 179 Tests on Vaginal Discharge. In: H Kenneth WALKER, MD, W Dallas HALL, MD, and J Willis HURST, MD. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworth Publishers. 1990. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/books/NBK288/
  5. National Institute for Health and Care Excellence guidelines. Last revised in August 2012. Viewed on 11/03/2014 http://cks.nice.org.uk/candida-female-genital#!diagnosissub:1
  6. SARASWATHI K. S, Farhana ALJABRI. Importance of Papanicolau (Pap) smear in Cervical Cancer screening in a tertiary care hospital. Scholars Research Library. Der Pharmacia Lettre, 2012, Volume 4. Issue 5. Pages1558-1559 Viewed on: 11/03/2014 http://scholarsresearchlibrary.com/dpl-vol4-iss5/DPL-2012-4-5-1558-1559.pdf
  7. SIVARANJINI R, T J JAISANKAR, Devinder Mohan THAPPA, Rashmi Kumari, Laxmisha CHANDRASEKHAR, M Malathi, SC PARIJA, S HABEEBULLAH. Spectrum of vaginal discharge in a tertiary care setting. 2013, Volume 3, Issue : 2, Page : 135-139 Viewed on: 11/03/2014 http://www.tropicalparasitology.org/article.asp?issn=2229-5070;year=2013;volume=3;issue=2;spage=135;epage=139;aulast=Sivaranjini
  8. MARRAZZO Jeanne M, Harold C. WIESENFELD, Pamela J. MURRAY, Barbara BUSSE, Leslie MEYN, Marijane KROHN and Sharon L. HILLIER. Risk Factors for Cervicitis among Women with Bacterial Vaginosis. The Journal of Infectious Diseases, Volume 193, Issue 5, Pg. 617-624 Viewed on: 12/03/2014 http://jid.oxfordjournals.org/content/193/5/617.full?sid=118b439b-f497-45f9-94e4-580ff68c9718

Investigations - for Diagnosis

Fact Explanation
pH of the discharge will be more than 4.5 Reduced lactobacilli leads to reduced acidification thus alkaline pH of the vaginal discharge.[1] Trichomoniasis may also show high pH. [2]
Positive whiff test Drops of 10% KOH into the vaginal discharge give rise to amine/ fishy odour. [3]
Wet mount of vaginal discharge showing clue cells The epithelial border is fuzzy with studded organisms in the border, the appearance of which is called the clue cells. Normal epithelium would have a well demarcated border. [3]
Gram stain of the endocervical swab showing grade III of modified Ison‐Hay scoring system. The clue cells can be clearly demonstrated. [4] The modified Ison‐Hay scoring system is as follows: Grade 0 - No bacteria Grade I - Normal vaginal flora Grade II - Reduced numbers of lactobacillus with a mixed flora Grade III - Only mixed flora, few or absent lactobacillus Grade IV - Gram positive cocci only. Grade III is considered as bacterial vaginosis which is in consistent with Amsel's criteria. [5] [6] This has proven to be an effective method than the clinical criterion. [7]
References
  1. ESCHENBACH DA, DAVICK PR, WILLIAMS BL, KLEBANOFF SJ, YOUNG-SK, CRITCHLOW CM, HOLMES KK. Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. PubMed. Journal of Clinical Microbiology. Feb 1989, Volume 27. Issue 2 Pages 251-6. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/?term=2915019%5Buid%5D%2B
  2. National Institute for Health and Care Excellence guidelines. Viewed on 11/03/2014 http://cks.nice.org.uk/bacterial-vaginosis#!topicsummary
  3. MAJERONI Barbara A., M.D., State University of New York at Buffalo, Buffalo, New York. Bacterial Vaginosis: An Update. American Family Physician. 1998 Mar 15; Volulme 57 Issue 6 Pages 1285-1289. Viewed on: 11/03/2014 http://www.aafp.org/afp/1998/0315/p1285.html
  4. KELLY Karen G. Chapter 179 Tests on Vaginal Discharge. In: H Kenneth WALKER, MD, W Dallas HALL, MD, and J Willis HURST, MD. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworth Publishers. 1990. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/books/NBK288/
  5. KEANE F, C A Ison, C ESTCOURT. Bacterial vaginosis. Sexually Transmitted Infections. Dec 2006. Volume 8. Viewed on: 11/03/2014 Available from: PMC2563898, doi: 10.1136/sti.2006.023119 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563898/
  6. AMSEL R, TOTTEN PA, SPIEGEL CA, CHEN KC, ESCHENBACH D, HOLMES KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. American Journal of Medicine. Jan 1983. Volume 74. Issue 1, Pages 14-22. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pubmed?term=6600371
  7. TAM M T, M YUNGBLUTH, and T MYLES. Gram stain method shows better sensitivity than clinical criteria for detection of bacterial vaginosis in surveillance of pregnant, low-income women in a clinical setting. Infectious Diseases of Obstetrics and Gynecology. 1998. Volume 6. Issue 5. Viewed on: 11/03/2014 Available at: PMC1784815. doi: 10.1002/(SICI)1098-0997(1998)6:5<204::AID-IDOG3>3.0.CO;2-R http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1784815/

Investigations - Screening/Staging

Fact Explanation
High vaginal swab Should be done in woman who are at risk of having other sexually transmitted illnesses. [1] And a wet mount of this would help to co existing trichomoniasis and candida. Also done in pregnant women who have past history of preterm delivery.
References
  1. National Institute for Health and Care Excellence guidelines. Viewed on: 11/03/2014 http://cks.nice.org.uk/bacterial-vaginosis#!topicsummary

Management - General Measures

Fact Explanation
Male partner treatment. Has not proven to benefit in the the recurrence of bacterial vaginosis. [1]
References
  1. COLLI E, M LANDONI, F PARAZINNI. Treatment of male partners and recurrence of bacterial vaginosis: a randomised trial. Genitourinary Medicine. Aug 1997; volume 73. Issue 4: Pages 267–270. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195855/

Management - Specific Treatments

Fact Explanation
Oral metronidazole 400 mg twice a day for 5 to 7 days. This is given to symptomatic non-pregnant women and both symptomatic and asymptomatic pregnant women. [1] Treatment of asymptomatic pregnant women is contradictory but strongly recommended in women with past history of preterm delivery [2] [3] Oral and intravaginal metronidazole seem to have the same outcome in pregnant women. [4]
Single oral dose of 2 g is used in treatment non-adherent women. The chances of relapse is high in this regimen and not recommended in pregnancy. [1]
Intravaginal metronidazole gel 0.75% once a day for 5 days or intravaginal clindamycin cream 2% once a day for 7 days. This is used in both pregnant and non-pregnant women who do not tolerate oral metronidazole or in those who prefer tropical treatment. [1]
Clindamycin 300 mg twice a day for 7 days Clindamycin is not usually used due to its infamous side effect profile. But can be used in both pregnanat and non-pregnant women. [1]
Probiotic Lactobacillus Augments the antibiotic therapy. [5]
Recurrence rate can be reduced by applying intravaginal metronidazole gel 0.75% twice weekly. Also 250 mg of ascorbic acid vaginal tablets used 6 days a month for 6 months has been proven to reduce recurrence. [6] Vitamine C acts by vaginal acidification replacing the action of hydrogen peroxide producing Lactobacillus which is reduced in bacterial vaginosis. [6]
References
  1. National Institute for Health and Care Excellence guidelines. Last revised in April 2013. Viewed on 11/03/2014 http://cks.nice.org.uk/bacterial-vaginosis#!topicsummary
  2. GUPTA S MBBS, MD; R TRIPATHI MB BS, MD; N SINGH MBBS, MS; P BHALLA MBBS, MD; S RAMJI MBBS, MD; Y M Mala MBBS, MD. Pregnancy outcome in asymptomatic women with abnormal vaginal flora without any treatment and after treatment with vaginal clindamycin and clotrimazole: A randomised controlled trial. South African journal of obstetrics and gynecology. Health & Medical Publishing Group. 2013. Volume 19. Viewed on: 11/03/2014 http://www.sajog.org.za/index.php/SAJOG/article/view/626/386
  3. McDONALD HM, BROCKELHURST P, GORDON A. Antibiotics for treating bacterial vaginosis in pregnancy.Antibiotics for treating bacterial vaginosis in pregnancy (Review). The Cochrane Collaboration. Wiley publishers. 2007, Issue 4. Viewed on: 11/03/2014 http://apps.who.int/rhl/reviews/CD000262.pdf
  4. MITCHELLE Caroline M, Jane E HITTI, David N FREDRICKS. Comparison of oral and vaginal metronidazole for treatment of bacterial vaginosis in pregnancy: impact on fastidious bacteria. BioMedCentral Infectious Diseases 2009. Volume 9. Viewed on: 11/03/2014 Available from: PMC2703644, doi: 10.1186/1471-2334-9-89 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2703644/
  5. ANUKAM K, OSAZUWA E, AHONKHAI I, NGWU M, OSEMENE G, BRUCE AW, REID G. Augmentation of antimicrobial metronidazole therapy of bacterial vaginosis with oral probiotic Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14: randomized, double-blind, placebo controlled trial. Microbes and Infection. Elsevier. May 2006. Volume 8, Issue 6, Pages 1450–1454. Viewed on: 11/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/16697231
  6. VLADISLAV N. KRASNOPOLSKY, VERA N. PRILEPSKYA, Franco POLATTI, Nina V. ZAROCHENTSEVA, GULDANA R. BAYRAMOVA, Maurizio CASERINI, Renata PALMIERID Efficacy of Vitamin C Vaginal Tablets as Prophylaxis for Recurrent Bacterial Vaginosis: A Randomised, Double-Blind, Placebo-Controlled Clinical Trial. PMC. Journal of clinical medicine research.Aug 2013; volume 5. Issue 4; Viewed on: 11/03/2014 Available from: PMC3712888 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3712888/